Background Although biologics have revolutionized treatment of juvenile idiopathic arthritis (JIA), many patients have active disease despite therapy [1]. Studies have shown benefit of dose intensification of infliximab in several conditions, including inflammatory bowel disease, psoriasis, and idiopathic uveitis [2, 3]. However, the safety and effectiveness of infliximab dose intensification have not been evaluated in JIA. Objectives We routinely use high doses of infliximab (10–20 mg/kg/dose) in children with recalcitrant JIA or complications thereof. The objective of this study was to review our experiences with high-dose infliximab in JIA. Methods We performed a retrospective review of children with JIA who received infliximab at ≥10 mg/kg/dose. We recorded all serious adverse events (SAE), medically important infections, and infusion reactions. We also recorded the ESR, physician global assessment of disease activity (MD global), and active joint count (AJC) at initiation of high dose infliximab and 3, 6, and 12 months thereafter. Institutional Review Board approval was obtained from the University of Alabama at Birmingham for this study. Results 75 subjects received a total of 1,367 infusions over 126.8 person-years. There were a total of 11 SAEs (8.7 / 100 person-years), seven of which were potentially related to therapy; and 10 infusion reactions (0.7%), two constituting anaphylaxis. Statistically significant improvements were observed in the AJC (median 0 [range 0 – 31] versus 2 [0 – 39]) and MD global (12 [0 – 31] versus 21 [0 – 80]) assessments of disease activity over the first year. Conclusions High dose infliximab resulted in improvements in markers of JIA disease activity. The incidence of SAEs with high dose infliximab was similar to that reported in long-term outcome of a randomized clinical trial of standard dose infliximab for JIA [4], and the incidence of infusion reactions was even lower. High dose infliximab appears safe and effective in the management of JIA. Future studies are necessary to compare prospectively dose intensification with alternative therapeutic options. References Shenoi S, Wallace CA. Paediatr Drugs. 2010;12:367. Kahn P, et al. Ophthalmology. 2006;113:860. Reguiero M, et al. Inflamm Bowel Dis. 2007;13:1093. Ruperto N, et al. Ann Rheum Dis. 2010;69:718. Acknowledgements We thank the patients and families for agreeing to dose amplification of infliximab in medically refractory disease. Disclosure of Interest None Declared

A published article ‘‘Contaminated heparin associated with adverse clinical events and activation of the contact system,’’ Kishimoto et al, New England Journal of Medicine, 2008; 358:2457-2467, demonstrated that contaminated heparin induced contact system activation. To better understand why only subpopulations of patients experienced contaminated heparin-induced anaphylactic reactions, we systematically examined the contact system proteins from 6 hemodialysis patient plasmas obtained from St Louis Children’s Hospital where contaminated heparin-induced anaphylactic reactions were initially established. We discovered that plasma from patients affected by contaminated heparin already showed an activated contact system. Therefore, the contaminated heparin-induced bradykinin production and the subsequent bradykinin-induced hypotension-associated adverse events revealed by an animal model and normal human plasma studies might not be the same molecular mechanism manifested by the affected patients. Heparin is the most highly sulfated naturally occurring glycosaminoglycan (GAG). Heparin is enriched in porcine, ovine, bovine intestines, or bovine lung entrails along with less sulfated GAGs, including heparan sulfate, dermatan sulfate, and chondroitin sulfate. These GAGs are made by all animal cells and are present in all tissues. Pharmaceutical grade heparin is prepared from crude heparin by the removal of the less sulfated GAGs, the so-called heparin by-product, from heparin. The highly charged heparin has much higher anticoagulation activities compared to the less sulfated heparin byproduct. In 2007 and 2008, hundreds of anaphylactic reactions and at least 149 deaths were associated with contaminated heparin. Published reports have suggested that the contaminants in heparin include an impurity, specifically dermatan sulfate, and a contaminant, oversulfated chondroitin sulfate (OSCS) presumed to derive from animal cartilage. We identified heparin contaminants as chemically oversulfated or chemically sulfated/desulfated heparin by-products. We further observed that treatment of normal human plasmas with several species of oversulfated GAGs, including OSCS, oversulfated heparan sulfate, oversulfated dermatan sulfate, and oversulfated heparin by-product (OS-HB), induced not only contact system activation (as indicated by the generation of kallikrein-like activity) but also thrombin-like activity. These observations suggest that the molecular mechanism underlying the contaminated heparin-associated adverse events might be more complex than the established model. To understand the contaminated heparininduced anaphylactic reactions, we systematically examined the contact system proteins from 6 hemodialysis patient plasmas. Patients H1 and H4 had typical anaphylactic reactions and patient H2 had delayed anaphylactic reactions induced by contaminated heparin during hemodialysis. The plasmas were obtained 4 and 5 months after the anaphylactic From the Departments of Pathology and Immunology, Washington University School of Medicine, St Louis, MO, USA (YQ, JP, XZ, PW, HL, AMB, LZ); and Pfizer Inc. Chesterfield MO, USA (FFS).

Oncogenic mutations create cancer cells. Cancer cells require thrombin for growth, angiogenesis, and metastasis. All cancer patients display a hypercoagulable state, which includes platelet activation, blood coagulation, complement activation, vasodilatation, and inflammation. This often results in thrombosis, the second leading cause of death in cancer patients. It is established that chemically oversulfated glycosaminoglycans (GAGs) induce thrombin generation through contact system activation in human plasma. Thrombin is responsible for thrombosis. In this chapter, we show that plasmas from lung cancer patients contain activated contact systems apparent by the absence of high molecular weight kininogen and processed C1inh, by abnormal kallikrein and thrombin activities, and by increased glucosamine, galactosamine, and GAG levels. Activated contact systems were also evident in plasmas from breast, colon, and pancreatic cancer patients. These data suggest that GAGs or other molecules produced by tumors induce abnormal thrombin generation through contact system activation. Therefore, the contact system and glycans represent new targets for cancer diagnosis, prevention, and treatment.

Heparin-induced thrombocytopenia (HIT) with thrombosis is the most severe side effect of heparin administration. HIT patients may die or have permanent sequelae, such as a stroke or limb amputation. Contaminated heparin is associated with anaphylactic reactions and deaths by activating the contact system. It is also associated with high incidence of HIT via a yet unknown mechanism. This chapter shows that: (1) the contact system can be activated by a variety of unrelated molecules; (2) kallikrein directly cuts prothrombin to generate functional thrombin through contact system activation; and (3) while heparin contaminants, oversulfated heparin by-product (OS-HB), induce thrombin generation in both normal and HIT patient plasmas through contact system activation, authentic heparin induces thrombin activities only in HIT patient plasmas containing autoantibodies against protein/heparin complex. These data suggest that the negatively charged IgG/protein/heparin or OS-HB complex activate the contact system and produce thrombin in human plasma and thrombin partially activates the platelets allowing subsequent platelet activation through IgG/Fc receptor II signaling. The newly discovered mechanism of heparin-induced thrombin activity could explain the increased incidence of HIT in patients exposed to contaminated heparin. Furthermore, the assays used in these studies would be valuable for HIT diagnosis, prevention, and treatment.

Systemic lupus erythematosus (SLE), heparin-induced thrombocytopenia (HIT), rheumatoid arthritis (RA) are marked by the presence of autoantibodies against negatively changed DNA, phospholipids, heparin, and chondroitin sulfate, respectively. Heparin/protein complexes induce contact system activation in HIT patient plasmas. The activated contact system generates thrombin. Thrombin is responsible for thrombosis, a common cause of death and disabilities for both HIT and SLE. In this chapter, we analyze plasma contact system proteins, thrombin- and kallikrein-like activities, glucosamine and galactosamine content from SLE-, RA-, osteoarthritis (OA)-, and psoriasis (Ps)-patient plasmas in addition to pooled 30+ healthy patient plasmas. We found that all SLE patient plasmas exhibited abnormal contact systems marked by the absence of high molecular weight kininogen, the presence of processed C1 inhibitor (C1inh), the display of abnormal thrombin- and kallikrein-like activities, and increased levels of plasma glucosamine and galactosamine. Different patterns of contact system activation distinguish SLE, RA, and Ps whereas no contact system activation is observed in normal and OA patient plasmas. The presence of paradoxical "lupus anticoagulants" in certain thrombosis-prone SLE patient plasmas, marked by delayed clotting in clinical plasma test, was explained by the consumption of contact system proteins, especially high molecular weight kininogen. Finally, we discovered that mouse and human SLE autoantibodies bind to cell surface GAGs with structural selectivity. In conclusion, markers of abnormal contact system activation represent potential new targets for autoimmune disease diagnosis, prevention, and treatment. These markers might also be useful in monitoring SLE activity/severity and in pinpointing patients with SLE-associated arthritis and psoriasis.

Contaminated heparin was linked to at least 149 deaths and hundreds of adverse reactions. Published report indicates that heparin contaminants were a natural impurity, dermatan sulfate, and a contaminant, oversulfated chondroitin sulfate (OSCS). OSCS was assumed to derive from animal cartilage. By analyzing 26 contaminated heparin lots from different sources, our data indicate that the heparin contaminants were chemically sulfated or chemically sulfated/desulfated glycosaminoglycans (GAGs) consisting of heparan sulfate, chondroitin sulfate, and dermatan sulfate based on monosaccharide quantification, CE, heparin lyase digestion, and liquid chromatography/mass spectrometry analysis. Since currently recommended heparin quality control assays had failed to detect certain heparin contaminants, a simple method that detects most contaminants in heparin was developed. This assay detects specific heparin structures that most contaminants cannot mimic and can be performed in any laboratory equipped with an UV spectrometer.

Thrombin generation is thought to be mediated predominantly by the tissue factor or "extrinsic" coagulation pathway. An alternate pathway to thrombin generation (the "intrinsic" pathway or contact system) has been observed when blood or plasma comes in contact with artificial surfaces. Here we present evidence for a new route to thrombin formation that begins with the activation of the contact system protein prekallikrein by oversulfated heparin (OS-HB). Kallikrein, instead of activated factor X, cleaves prothrombin to form thrombin. Thrombin then cleaves fibrinogen to form fibrin clots. Moreover, we show that OS-HB by-products induce kallikrein- and thrombin-like activities in normal human plasma and in human plasma devoid of coagulation factor X or downstream contact system components factor IX or factor XI. Oversulfated heparin by-product-induced thrombin generation may have had a role in the adverse reactions associated with the recent clinical use of contaminated heparin.

Rheumatoid arthritis (RA) is a heterogeneous autoimmune disease that affects 1% of the population worldwide. In the K/BxN mouse model of RA, autoantibodies specific for glucose-6-phosphate isomerase (GPI) from these mice can transfer joint-specific inflammation to normal mice. The binding of GPI/autoantibody to the cartilage surface is a prerequisite for autoantibody-induced joint-specific inflammation in the mouse model. Chondroitin sulfate (CS) on cartilage surface is the long sought high-affinity receptor for GPI. The binding affinity and structural differences between mouse paw/ankle CS and knee/elbow CS correlate with the distal to proximal disease severity in these joints. The data presented in this chapter indicate that autoantigen/autoantibodies in blood circulation activate contact system to produce vasodilators to allow immune complex, protein aggregates, and other plasma proteins to get into the joints. Cartilage surface CS binds and retains autoantigen/autoantibodies. The CS/autoantigen/autoantibody complexes could induce C3a and C5a production through contact system activation. C3a and C5a trigger degranulation of mast cells, which further recruit plasma contact system and complement proteins, immune cells, and immune activation factors to facilitate joint-specific tissue destruction. Therefore, either reducing autoantibody production or inhibiting autoantibody-induced contact system activation might be effective in RA prevention.

In the K/BxN mouse model of rheumatoid arthritis, autoantibodies specific for glucose-6-phosphate isomerase (GPI) can transfer joint-specific inflammation to most strains of normal mice. Binding of GPI and autoantibody to the joint surface is a prerequisite for joint-specific inflammation. However, how GPI localizes to the joint remains unclear. We show that glycosaminoglycans (GAGs) are the high affinity (83 nm) joint receptors for GPI. The binding affinity and structural differences between mouse paw/ankle GAGs and elbows/knee GAGs correlated with the distal to proximal disease severity in these joints. We found that cartilage surface GPI binding was greatly reduced by either chondroitinase ABC or beta-glucuronidase treatment. We also identified several inhibitors that inhibit both GPI/GAG interaction and GPI enzymatic activities, which suggests that the GPI GAG-binding domain overlaps with the active site of GPI enzyme. Our studies raise the possibility that GAGs are the receptors for other autoantigens involved in joint-specific inflammatory responses.

We have investigated the role of pairing centers (PCs), cis-acting sites required for accurate segregation of homologous chromosomes during meiosis in C. elegans. We find that these sites play two distinct roles that contribute to proper segregation. Chromosomes lacking PCs usually fail to synapse and also lack a synapsis-independent stabilization activity. The presence of a PC on just one copy of a chromosome pair promotes synapsis but does not support synapsis-independent pairing stabilization, indicating that these functions are separable. Once initiated, synapsis is highly processive, even between nonhomologous chromosomes of disparate lengths, elucidating how translocations suppress meiotic recombination in C. elegans. These findings suggest a multistep pathway for chromosome synapsis in which PCs impart selectivity and efficiency through a “kinetic proofreading” mechanism. We speculate that concentration of these activities at one region per chromosome may have coevolved with the loss of a point centromere to safeguard karyotype stability.

The him-8 gene is essential for proper meiotic segregation of the X chromosomes in C. elegans. Here we show that loss of him-8 function causes profound X chromosome-specific defects in homolog pairing and synapsis. him-8 encodes a C2H2 zinc-finger protein that is expressed during meiosis and concentrates at a site on the X chromosome known as the meiotic pairing center (PC). A role for HIM-8 in PC function is supported by genetic interactions between PC lesions and him-8 mutations. HIM-8 bound chromosome sites associate with the nuclear envelope (NE) throughout meiotic prophase. Surprisingly, a point mutation in him-8 that retains both chromosome binding and NE localization fails to stabilize pairing or promote synapsis. These observations indicate that stabilization of homolog pairing is an active process in which the tethering of chromosome sites to the NE may be necessary but is not sufficient.

NOD mice develop type 1 autoimmune diabetes and exhibit genetically dominant resistance to transplantation tolerance induction. These two phenotypes are genetically separable. Costimulation blockade fails to prolong skin allograft survival in (NOD x C57BL/6)F1 mice and in NOD-related strains made diabetes-resistant by congenic introduction of protective major histocompatibility complex (MHC) or non-MHC Idd region genes. Here, we tested the hypothesis that the genetic basis for the resistance of NOD mice to skin allograft tolerance also applies to islet allografts. Surprisingly, costimulation blockade induced permanent islet allograft survival in (NOD x C57BL/6)F1 mice but not in NOD mice. After costimulation blockade, islet allograft survival was prolonged in diabetes-resistant NOD.B6 Idd3 mice and shortened in diabetes-free C57BL/6 mice congenic for the NOD Idd3 variant. Islet allograft tolerance could not be induced in diabetes-resistant NOD.B10 Idd5 and NOD.B10 Idd9 mice. The data demonstrate that 1) NOD mice resist islet allograft tolerance induction; 2) unlike skin allografts, resistance to islet allograft tolerance is a genetically recessive trait; 3) an Idd3 region gene(s) is an important determinant of islet allograft tolerance induction; and 4) there may be overlap in the mechanism by which the Idd3 resistance locus improves self-tolerance and the induction of allotolerance.

Thymocytes from adult BB rats can adoptively transfer autoimmune diabetes to athymic recipients. It is also known that the development of BB rat T-cells is recapitulated in adult thymus organ cultures (ATOCs). Based on these observations, we tested the hypothesis that cells capable of the adoptive transfer of diabetes would be present in long-term ATOCs but could be rendered nondiabetogenic by co-culture with appropriate antigens. We observed that cells recovered from adult diabetes-resistant BB (BBDR) rat thymi cultured for up to 14 days can adoptively transfer disease to athymic WAG-rnu/rnu rats treated with polyinosinic: polycytidylic acid and a monoclonal antibody to preclude development of ART2a+ regulatory T-cells. Co-culture of adult BBDR thymi in the presence of BBDR thyrocytes had no effect on the ability of recovered cells to induce diabetes in 70-80% of adoptive recipients. In contrast, co-culture in the presence of islets prevented transfer of diabetes, on average, in >90% of recipients. Fresh islets, frozen islets, and islets pretreated with streptozotocin to deplete insulin were equally effective in preventing diabetes, but none prevented insulitis in nondiabetic recipients. Co-culture in the presence of islets was not associated with detectable alterations in phenotype or in the secretion of gamma-interferon or interleukin-4, either in cultures or in cells recovered from adoptive recipients. We conclude that islet antigens involved in the initiation of autoimmune diabetes in BB rats may be absent or deficient in BB rat thymi. Exposure of ATOCs to exogenous islets may lead to deletion or anergy of diabetogenic T-cells or to the positive selection of regulatory T-cells.

Congenitally lymphopenic diabetes-prone (DP) BioBreeding (BB) rats develop spontaneous T cell-dependent autoimmunity. Coisogenic diabetes-resistant (DR) BB rats are not lymphopenic and are free of spontaneous autoimmune disease, but become diabetic in response to depletion of RT6+ T cells. The basis for the predisposition to autoimmunity in BB rats is unknown. Abnormal T cell development in DP-BB rats can be detected intrathymically, and thymocytes from DR-BB rats adoptively transfer diabetes. The mechanisms underlying these T cell developmental abnormalities are not known. To study these processes, we established adult thymus organ cultures (ATOC). We report that cultured DR- and DP-BB rat thymi generate mature CD4 and CD8 single-positive cells with up-regulated TCRs. DR-BB rat cultures also generate T cells that express RT6. In contrast, DP-BB rat cultures generate fewer CD4+, CD8+, and RT6+ T cells. Analysis of the cells obtained from ATOC suggested that the failure of cultured DP-BB rat thymi to generate T cells with a mature phenotype is due in part to an increased rate of apoptosis. Consistent with this inference, we observed that addition of the general caspase inhibitor Z-VAD-FMK substantially increases the number of both mature and immature T cells produced by DP-BB rat ATOC. We conclude that cultured DR-BB and DP-BB rat thymi, respectively, recapitulate the normal and abnormal T cell developmental kinetics and phenotypes observed in these animals in vivo. Such cultures should facilitate identification of the underlying pathological processes that lead to immune dysfunction and autoimmunity in BB rats.

Stimulation of CD4+ helper T lymphocytes by antigen-presenting cells requires the degradation of exogenous antigens into antigenic peptides which associate with major histocompatibility complex (MHC) class II molecules in endosomal or lysosomal compartments. B lymphocytes mediate efficient antigen presentation first by capturing soluble antigens through clonally distributed antigen receptors (BCRs), composed of membrane immunoglobulin (Ig) associated with Ig-α/Ig-β heterodimers which, second, target antigens to MHC class II–containing compartments. We report that antigen internalization and antigen targeting through the BCR or its Ig-α–associated subunit to newly synthesized class II lead to the presentation of a large spectrum of T cell epitopes, including some cryptic T cell epitopes. To further characterize the intracellular mechanisms of BCR-mediated antigen presentation, we used two complementary experimental approaches: mutational analysis of the Ig-α cytoplasmic tail, and overexpression in B cells of dominant negative syk mutants. Thus, we found that the syk tyrosine kinase, an effector of the BCR signal transduction pathway, is involved in the presentation of peptide– MHC class II complexes through antigen targeting by BCR subunits.

Membrane-bound immunoglobulin (mIg) of the IgG, IgA, and IgE classes have conserved cytoplasmic tails. To investigate the function of these tails, a B cell line was transfected with truncated or mutated γ2a heavy chains. Transport to the endosomal compartment of antigen bound by the B cell antigen receptor did not occur in the absence of the cytoplasmic tail; and one or two mutations, respectively, in the Tyr-X-X-Met motif of the tail partially or completely interrupted the process. Experiments with chimeric antigen receptors confirmed these findings. Thus, a role for the cytoplasmic tail of mIg heavy chains in endosomal targeting of antigen is revealed.

The B cell antigen receptor of class IgM is a multimeric protein complex containing the membrane-bound immunoglobulin molecule and a heterodimer of the two B cell-specific transmembrane proteins Ig-alpha and Ig-beta. The B cell antigen receptor fulfills a dual role on the surface of B cells. First, it is a signal transduction complex which can activate protein tyrosine kinases and induce the release of Ca2+ ions from intracellular stores. Second, its internalization mediates the specific uptake of bound antigens, which are processed intracellularly and presented as major histocompatibility complex-bound peptides on the cell surface. In case of the IgM antigen receptor, the association with the heterodimer is necessary for expression of large amounts of IgM on the surface. We show here that the IgG2a antigen receptor can be expressed on the surface of myeloma cells in two structurally different forms: either with or without the Ig-alpha/Ig-beta heterodimer. A functional comparison of the two forms of antigen receptors demonstrates that the Ig-alpha and Ig-beta molecules are required for the activation of protein tyrosine kinases after cross-linking of the B cell antigen receptor. In contrast, both forms of IgG2a are equally well internalized. This suggests that Ig-alpha and Ig-beta are essential for signal transduction through the IgG2a antigen receptor, whereas internalization can occur independently of the heterodimer.